Active NPI
Patrick G Eagle Staff, PWS/QMHP-C
- Peer Specialist
- Portland, OR
National Provider Identifier
1316477441
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- THW0002219
- Practice address
- 1310 SW 17TH Ave
Portland, OR 97201-2522 - Phone
- (503) 231-2641
- Fax
- (503) 467-4077
- NPI assigned
- Jun 12, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 19-QMHPC-00380 | OR | |
| Peer Specialist | 175T00000X | THW0002219 | OR | Primary |
Addresses
Primary practice location
1310 SW 17TH Ave
Portland, OR 97201-2522
Mailing address
1776 SW Madison St
Portland, OR 97205-1715
Phone (971) 386-2278
Other practice location 1
620 NE 2nd St
Gresham, OR 97030-7514
Phone (971) 274-3757
Other practice location 2
1631 SW Columbia St
Portland, OR 97201-6025
Phone (503) 621-2235
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 500761421 | Medicaid | OR | |
| 500733968 | Medicaid | OR |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19-QMHPC-00380 | OR | MD | Mental Health Counselor |
| THW0002219 | OR | MD | Peer Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1497225600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1558656000000",
"number": "1316477441",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1776 SW MADISON ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972051715",
"telephone_number": "971-386-2278",
"fax_number": "503-224-4494"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1310 SW 17TH AVE",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972012522",
"telephone_number": "503-231-2641",
"fax_number": "503-467-4077"
}
],
"practiceLocations": [
{
"address_1": "620 NE 2nd St",
"address_purpose": "LOCATION",
"city": "Gresham",
"state": "OR",
"postal_code": "970307514",
"country_code": "US",
"telephone_number": "971-274-3757",
"fax_number": "503-912-5740",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "1631 SW Columbia St",
"address_purpose": "LOCATION",
"city": "Portland",
"state": "OR",
"postal_code": "972016025",
"country_code": "US",
"telephone_number": "503-621-2235",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "EAGLE STAFF",
"first_name": "PATRICK",
"middle_name": "G",
"credential": "PWS/QMHP-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-06-12",
"last_updated": "2019-05-24",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "OR",
"license": "19-QMHPC-00380",
"primary": false
},
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "OR",
"license": "THW0002219",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500761421",
"state": "OR"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500733968",
"state": "OR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Portland, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.